Ambulatory Care

Jennifer Lukela, M.D.
Associate Program Director


The majority of medical care occurs in the ambulatory setting. As a result, internists must be comfortable evaluating and managing both acute complaints and chronic conditions outside the hospital.

A goal of the University of Michigan Internal Medicine Residency Program is that all our graduates will be comfortable with the practice of general internal medicine in the outpatient setting. While the majority of our residents will elect to pursue further training after residency in subspecialty practice, we believe these core skills in outpatient general medicine will serve them well in aspects of their future practice and in their overall development as internists.

Ambulatory education

Outpatient clinical experiences

Our residents gain clinical experience in the practice of Internal Medicine in the outpatient setting through three main rotations or longitudinal experiences:

  • Continuity Clinics
  • Ambulatory Block Rotations
  • Outpatient Clinical Electives
    • Continuity Clinics
      Residents will be assigned to a continuity clinic in one of three locations:
      1. Taubman General Medicine Clinic (located in an outpatient building adjacent to University Hospital)
      2. General Medicine Clinic at the Ann Arbor VA Hospital
      3. One of four UMHS Clinics located in our local community:
    • Briarwood Medical Group
    • Brighton Health Center
    • Canton Health Center
    • East Ann Arbor Health Center

    A primary goal of our continuity clinic experience is for residents to maintain longitudinal relationships with patients throughout their training. Since all of our continuity clinic sites serve as Patient Centered Medical Homes, this is an opportunity for our residents to gain experience in panel management and general quality improvement (QI) principles in population health.

    On average, residents are scheduled for one half day of continuity clinic per week with additional time in their assigned clinic during their Ambulatory Block Rotations.

    Ambulatory Block Rotation

    The Ambulatory Block Rotation combines general and subspecialty outpatient experiences supplemented with didactic sessions and self-directed learning focused on broadening medical knowledge pertinent to the outpatient clinical setting. Upon successful completion of these rotations, residents will be able to diagnose and manage a wide range of acute and chronic internal medicine disease states. Residents will understand the logistics of care in the ambulatory setting and have the ability to work in a variety of practice environments. They will also be familiar with the care of a variety of patient populations in the ambulatory setting.

    This rotation is mandatory for residents at all house officer levels. All interns will complete at least one ambulatory block rotation (primary care track residents may have the opportunity for two rotations). Senior residents will complete 1-2 ambulatory block rotations per year with additional outpatient training opportunities for residents participating in the primary care track.

    In the HO1 year, the Ambulatory Block Rotation will include an emphasis on primary care medicine in the community setting along with exposure to under-served and high risk populations. There will also be ample time in continuity clinic to allow interns to begin to build their patient panel and develop increased confidence in their continuity clinic setting.

    In the HO2 and HO3 years, the Ambulatory Block Rotations will focus more on subspecialty clinical experiences highly relevant to primary care practice (ie, ophthalmology, gynecology, ENT).

    Sample Ambulatory Block Rotation Schedule:


    Ambulatory Morning Report

    Ambulatory Morning Report

    Ambulatory Morning Report

    Ambulatory Morning Report

    Ambulatory Morning Report


    Gen Med/PC




    Ophthalmology- 1st and 3rd week
    (alternates with reading time)


    Primary Care Clinic

    Primary Care Clinic

    General Endocrine Clinic



    Gen Med/PC

    ENT Clinic

    Spine (BW)



    Rheum Procedures Clinic
    2nd and 4th week
    (alternates w/reading time)


    Outpatient Clinical Electives

    Many specialties within Internal Medicine (ie, Cardiology, Endocrine, Oncology) also have a large component of their practice that occurs in the ambulatory settings. In order for our house officers to get additional training in these settings, residents may choose from a variety of outpatient electives. There is also a formal, self-directed curriculum in the outpatient specialty clinics.

    Didactic experiences in ambulatory medicine

    Clinical experiences in outpatient medicine are supplemented by a variety didactic conferences and opportunities which cover topics and skills particularly relevant to outpatient medicine.

    In their Continuity Clinics, residents will participate in bimonthly conferences with clinic preceptors to complete on line learning modules or engage in case-based discussions related to patients seen in their clinic.

    During the Ambulatory Block Rotations, residents attend a daily Ambulatory Morning Report, a case-based conference which focuses on evaluation and management of common ambulatory complaints and conditions. Ambulatory Block Rotations also include required attendance in a half day of didactics on Thursday afternoons called Teaching and Learning Seminars (TLS). These sessions include a focus on evidence based medicine, patient safety, selected topics in outpatient medicine like endocrine and geriatrics and training in medical education. Each ambulatory block also includes a half day of protected time to allow residents an opportunity for self-directed and on-line learning.

    In the HO2 year, at least one Ambulatory Block Rotation for each resident will include dedicated time for additional training in patient safety along with the opportunity to complete a patient safety and quality improvement project.